Variation in quality of care among older men with localized prostate cancer

BACKGROUND:

The objective of this study was to assess the racial and ethnic disparities in outcomes and their association with process‐of‐care measures for elderly Medicare recipients with localized prostate cancer.

METHODS:

The Surveillance, Epidemiology, and End Results‐Medicare databases for the period from 1995 to 2003 were used to identify African‐American men, non‐Hispanic white men, and Hispanic men with localized prostate cancer, and data were obtained for the 1‐year period before the diagnosis of prostate cancer and up to 8 years postdiagnosis. The short‐term outcomes of interest were complications, emergency room visits, readmissions, and mortality; the long‐term outcomes of interest were prostate cancer‐specific mortality and all‐cause mortality; and process‐of‐care measures of interest were treatment and time to treatment. Cox proportional hazards regression, logistic regression, and Poisson regression were used to study the racial and ethnic disparities in outcomes and their association with process‐of‐care measures.

RESULTS:

Compared with non‐Hispanic white patients, African‐American patients (Hazard ration [HR], 1.43; 95% confidence interval [CE], 1.19‐1.86) and Hispanic patients (HR=1.39; 95% CI, 1.03‐1.84) had greater hazard of long term prostate specific mortality. African‐American patients also had greater odds of emergency room visits (odds ratio, 1.4; 95% CI, 1.2‐1.7) and greater all‐cause mortality (HR, 1.39; 95% CI, 1.3‐1.5) compared with white patients. The time to treatment was longer for African‐American patients and was indicative of a greater hazard of all‐cause, long‐term mortality. Hispanic patients who underwent surgery or received radiation had a greater hazard of long‐term prostate‐specific mortality compared with white patients who received hormone therapy.

CONCLUSIONS:

Racial and ethnic disparities in outcomes were associated with process‐of‐care measures (the type and time to treatment). The current results indicated that there is an opportunity to reduce these disparities by addressing these process‐of‐care measures. Cancer 2011. © 2010 American Cancer Society.     

Patterns of care and treatment trends for Canadian men with localized low-risk prostate cancer: an analysis of provincial cancer registry data

BackgroundMany prostate cancers (pcas) are indolent and, if left untreated, are unlikely to cause death or morbidity in a man’s lifetime. As a result of testing for prostate-specific antigen, more such cases are being identified, leading to concerns about “overdiagnosis” and consequent overtreatment of pca. To mitigate the risks associated with overtreatment (that is, invasive therapies that might cause harm to the patient without tangible benefit), approaches such as active surveillance are now preferred for many men with low-risk localized pca (specifically, T1/2a, prostate-specific antigen ≤ 10 ng/mL, and Gleason score ≤ 6). Here, we report on patterns of care and treatment trends for men with localized low-risk pca.ResultsThe provinces varied substantially with respect to the types of primary treatment received by men with localized low-risk pca. From 2010 to 2013, many men had no record of surgical or radiation treatment within 1 year of diagnosis—a proxy for active surveillance; the proportion ranged from 53.3% in Nova Scotia to 80.8% in New Brunswick. Among men who did receive primary treatment, the use of radical prostatectomy ranged from 12.0% in New Brunswick to 35.9% in Nova Scotia. The use of radiation therapy (external-beam radiation therapy or brachytherapy) ranged from 4.1% in Newfoundland and Labrador to 17.6% in Alberta. Treatment trends over time suggest an increase in the use of active surveillance. The proportion of men with low-risk pca and no record of surgical or radiation treatment rose to 69.9% in 2013 from 46.1% in 2010 for all provinces combined.ConclusionsThe provinces varied substantially with respect to patterns of care for localized low-risk pca. Treatment trends over time suggest an increasing use of active surveillance. Those findings can further the discussion about the complex care associated with pca and identify opportunities for improvement in clinical practice.     

Secondary bladder cancer after anticancer therapy for prostate cancer: reduced comorbidity after androgen-deprivation therapy

Radiotherapy for prostate cancer is associated with an increased incidence of secondary bladder cancer (BC). We investigated the incidence, clinicopathological characteristics, and prognosis of BC after radiotherapy, surgical therapy, and primary androgen-deprivation therapy (ADT) for prostate cancer. This study included 1,334 Japanese patients with prostate cancer treated with radiotherapy (n=631), surgical therapy (n=437), and primary ADT (n=266). During the median follow-up period of 51.2, 44.8, and 45.5 months, secondary BC occurred in 14 (2.2%), 5 (1.1%), and 0 (0%) of patients with prostate cancer treated with radiotherapy, surgical therapy, and primary ADT, respectively. The 10-year BC-free survival rate was 91.3% in the radiotherapy group, 97.4% in the surgical therapy group, and 100% in the primary ADT group. The rates of intravesical recurrence, progression to muscle-invasive BC, and BC-specific death might be higher in secondary BC after radiotherapy compared with after surgical therapy. There was a significant difference in the incidence of secondary BC among different therapeutic modalities for prostate cancer in Japanese men, indicating significantly lower comorbidity rates of secondary BC after primary ADT for prostate cancer compared with radiotherapy.     

Treatment and survival outcomes in young men diagnosed with prostate cancer

BACKGROUND:

Outcomes of treatment for young men compared with older men with prostate cancer are poorly defined outside of limited institutional series. In this study, the authors examined the association between age at diagnosis and grade, stage, treatment, and survival outcomes in men who were diagnosed during the era of prostate‐specific antigen testing.

METHODS:

The National Cancer Institute's Surveillance, Epidemiology, and End Results database was used to identify men who were diagnosed with prostate cancer between 1988 and 2003. Men ages 35 years to 74 years were stratified by age at diagnosis to examine differences in tumor characteristics, treatment, and survival within each age group.

RESULTS:

In total, 318,774 men ages 35 years to 74 years were identified who had been diagnosed with adenocarcinoma of the prostate between 1988 and 2003. The proportion of men aged ≤55 years at diagnosis increased over the study period from 2.3% between the years 1988 and 1991 to 9% between the years 2000 and 2003, and the median age at diagnosis decreased from 72 years in 1988 to 68 years in 2003. Younger men were diagnosed less frequently with organ‐confined tumors (P < .001) but were less likely to be diagnosed with high‐grade cancer (P < .001). Older men were more likely to receive no local therapy or external beam radiation than young men (P < .001 for trend). Among men who had tumors with a Gleason score between 5 and 7, overall survival was worse with advancing age. However, among all age groups with high grade and stage, the youngest men (ages 35‐44 years) were at the highest risk of all‐cause and cancer‐specific death.

CONCLUSIONS:

Age at diagnosis among men with prostate cancer continued to decline. Younger men were more likely to undergo prostatectomy, have lower grade cancer, and, as a group, to have better overall and equivalent cancer‐specific survival at 10 years compared with older men. Among men with high grade and locally advanced prostate cancer, the youngest men had a particularly poor prognosis compared with older men. Cancer 2009. Published 2009 by the American Cancer Society.     

Sequential treatment for recurrent localized prostate cancer

To compare toxicity and efficacy of both salvage prostatectomy and salvage radiotherapy for prostate cancer a retrospective analysis was conducted. Thirty-two and 41 patients were treated with external beam radiotherapy or prostatectomy for cT1c-T2 prostate cancer later requiring salvage surgery or radiotherapy. Salvage surgery was performed when a local recurrence was biopsy confirmed and life-expectancy was more than 10 years. Salvage external beam radiotherapy was performed when PSA rose over 0.1 ng/ml in the absence of systemic disease. Ten-year PSA-recurrence free survival after primary treatment in the salvage surgery group and salvage radiotherapy groups was 55% and 44% (P > 0.05) respectively whereas prostate cancer specific survival was 93% and 89%, respectively (P > 0.05). Both, biopsy Gleason score prior to primary treatment and PSADT prior to salvage treatment were predictive of PSA-recurrence free survival. Patients after salvage radiotherapy (13%) were less likely to wear pads for urinary incontinence compared to patients after salvage surgery (56%). Erectile dysfunction was more frequent after salvage surgery (81%) compared to salvage radiotherapy (61%). Salvage surgery and salvage prostatectomy after primary cT1-2 prostate cancer provide comparable PSA-recurrence free survival after primary treatment. Genitourinary functions were better preserved in the salvage radiotherapy group compared to the salvage prostatectomy group.     

Salvage laparoscopic surgery in advanced prostate cancer: is it possible or beneficial?

Purpose: The surgical management of recurrent urological cancer continues to evolve. This review focuses on the role laparoscopic surgical techniques have within recurrent prostate treatments. Methods: A literature search from 1990 to 2007 was conducted using the PubMed database to determine the role of laparoscopic salvage surgery for prostate cancers. In all articles studied, we evaluated: estimated blood loss; transfusion rates; hemoglobin level; serum and drain fluid creatinine levels; bowel injury; hospital stay and complication rates. Results: Laparoscopic surgery is used regularly for the treatment of urological cancers; however, its role in treating radiorecurrent or chemoradiorecurrent cancer is unknown. Adjuvant chemo-radiotherapy, other experimental localized therapies (cryotherapy) or hormonal therapy are known to affect the operative field, causing greater morbidity in open surgery. Relative survival rates were lowest among patients who received no treatment and highest among patients who underwent surgical procedures. Conclusions: Although associated with significant morbidity, salvage prostatectomy remains a viable form of therapy. Laparoscopic salvage radical prostatectomy for recurrent cancer is feasible with no more morbidity than an open procedure, with promising short-term oncologic and functional outcomes. Long-term data will ultimately confirm the viability of the laparoscopic approach most probably in a multicenter setting.     

Androgen deprivation therapy in nonmetastatic prostate cancer patients: Indications,treatment effects,and new predictive biomarkers

Men with prostate cancer with positive margins, extraprostatic extension, positive lymph nodes, high prostate‐specific antigen, or high Gleason Score are at high risk of recurrence following primary therapy. Androgen deprivation therapy (ADT), which includes medical/surgical castration, antiandrogen therapy, and combined androgen blockade, can be combined with primary therapy to shrink the tumor, reduce margin positivity, and reduce the risk of recurrence. However, many problems still remain, such as optimizing the application of ADT in the treatment of prostate cancer, for example, ideal patient population and optimal timing and duration of therapy. To investigate these problems, we searched PubMed for relevant publications on clinical studies of deprivation therapy for nonmetastatic prostate cancer. In this review, we discuss our findings on the role of ADT in the treatment of castrate‐sensitive nonmetastatic prostate cancer and the adverse effects associated with ADT. We also examine the recent advances in new predictive biomarkers for ADT, many of which are currently in the exploratory phase. Overall, the addition of ADT to primary therapy improves outcomes for patients with intermediate‐ or high‐risk prostate cancer.     

Key papers in prostate cancer

Prostate cancer is the most common cancer and second leading cause of death in men. The evidence base for the diagnosis and treatment of prostate cancer is continually changing. We aim to review and discuss past and contemporary papers on these topics to provoke debate and highlight key dilemmas faced by the urological community. We review key papers on prostate-specific antigen screening, radical prostatectomy versus surveillance strategies, targeted therapies, timing of radiotherapy and alternative anti-androgen therapeutics. Previously, the majority of patients, irrespective of risk, underwent radical open surgical procedures associated with considerable morbidity and mortality. Evidence is emerging that not all prostate cancers are alike and that low-grade disease can be safely managed by surveillance strategies and localized treatment to the prostate. The question remains as to how to accurately stage the disease and ultimately choose which treatment pathway to follow.     

Retropubic versus perineal radical prostatectomy in early prostate cancer: eight-year experience

BACKGROUND: Prostate cancer is the most common malignancy in men and the second leading cause of cancer death. A randomized study was performed on patients with localized prostate cancer and treated with radical prostatectomy using the perineal or the retropubic approach comparing oncological outcomes, cancer control, and functional results. STUDY DESIGN: Between 1997 and 2004, in a randomized study 200 patients underwent a radical prostatectomy performed by retropubic (100 patients) or perineal (100 patients) approach. RESULTS: Differences between hospital stay, duration of catheter drainage, intraoperative blood loss, and transfusion requirements were statistically significant in favor of perineal prostatectomy. Differences between positive surgical margins and urinary continence in the two groups were not statistically significant at 6 and 24 months. Differences between erectile function at 24 months were statistically significant in favor of retropubic prostatectomy. CONCLUSIONS: Radical perineal prostatectomy is an excellent alternative approach for radical surgery in the treatment of early prostate cancer.     

The quality of surgical pathology care for men undergoing radical prostatectomy in the U.S

BACKGROUND: The authors assessed adherence with the College of American Pathologists (CAP) radical prostatectomy (RP) practice protocol in a national sample of men who underwent RP for early-stage prostate cancer. METHODS: Using the National Cancer Data Base, the authors identified a nationally representative sample of 1240 men (unweighted) who underwent RP. For each patient, local cancer registrars performed an explicit medical record review to assess patient-level compliance with surgical pathology report documentation of 7 morphologic criteria (ie, quality indicators). Applying the CAP prognostic factor classification framework, composite measures and all-or-none measures of quality indicator compliance were calculated for the following analytic categories: 1) a strict subset of CAP category I prognostic factors (3 indicators), 2) a broad subset of CAP category I factors (6 indicators), and 3) the full set of 7 indicators. RESULTS: Among a weighted sample of 24,420 patients who underwent RP, compliance with documentation of the CAP category I factors varied from 54% (95% confidence interval [95% CI], 50-58%) for pathologic tumor, lymph node, metastases classification (according to the American Joint Committee on Cancer staging system) to 97% (95% CI, 96-99%) for Gleason score. In composite, RP pathology reports contained 83% (95% CI, 81-84%), 85% (95% CI, 84-87%), and 79% (95% CI, 78-80%) of the recommended data elements measured by the strict CAP category I subset, the broad CAP category I subset, and the full set of 7 indicators, respectively. In contrast to the generally higher composite scores, only 52% (95% CI, 48-56%) and 41% (95% CI, 37-45%) of men who underwent RP had complete documentation in their pathology reports for the strict and broad CAP category I subsets, respectively. CONCLUSIONS: RP surgical pathology reports contained most of the recommended data elements; however, the frequent absence of pathologic stage provides an opportunity for quality improvement.     

Association between the polygenic liabilities for prostate cancer and breast cancer with biochemical recurrence after radical prostatectomy for localized prostate cancer

Prostate and breast cancers are hormone-related malignancies and are characterized by a complex interplay of hundreds of susceptibility loci throughout the genome. Prostate cancer could be inhibited by eliminating androgens through castration or estrogen administration, thus facilitating long-term treatment of prostate cancer; however, the role of estrogen in prostate cancer remains unclear. This study aimed to determine whether polygenic risk scores (PRSs) comprising combinations of genome-wide susceptibility variants influence the clinical outcomes of prostate cancer patients. The study subjects were recruited from four medical centers in Taiwan, and genome-wide genotyping data were obtained from 643 prostate cancer patients. We derived the PRS for prostate cancer (PRS-PC) and for breast cancer (PRS-BC) for each patient. The association between the PRS-PC/PRS-BC at the age of prostate cancer onset and recurrence within seven years was evaluated using a regression model adjusted for population stratification components. A higher PRS-PC was associated with an earlier onset age for prostate cancer (beta in per SD increase in PRS = -0.89, P = 0.0008). In contrast, a higher PRS-BC was associated with an older onset age for prostate cancer (beta = 0.59, P = 0.02). PRS-PC was not associated with the risk of recurrence (hazard ratio = 1.03, P = 0.67), whereas a higher PRS-BC was associated with a low recurrence risk (hazard ratio = 0.86, P = 0.03). These results indicate that the genetic predisposition to breast cancer is associated with a low risk of prostate cancer recurrence. Further studies are warranted to explore the role of breast cancer susceptibility variants and estrogen signaling in prostate cancer progression.     

Undetectable ultrasensitive PSA after radical prostatectomy for prostate cancer predicts relapse-free survival

Radical retropubic prostatectomy is considered by many centres to be the treatment of choice for men aged less than 70 years with localized prostate cancer. A rise in serum prostate-specific antigen after radical prostatectomy occurs in 10-40% of cases. This study evaluates the usefulness of novel ultrasensitive PSA assays in the early detection of biochemical relapse. 200 patients of mean age 61. 2 years underwent radical retropubic prostatectomy. Levels < or = 0.01 ng ml-1 were considered undetectable. Mean pre-operative prostate-specific antigen was 13.3 ng ml-1. Biochemical relapse was defined as 3 consecutive rises. The 2-year biochemical disease-free survival for the 134 patients with evaluable prostate-specific antigen nadir data was 61.1% (95% CI: 51.6-70.6%). Only 2 patients with an undetectable prostate-specific antigen after radical retropubic prostatectomy biochemically relapsed (3%), compared to 47 relapses out of 61 patients (75%) who did not reach this level. Cox multivariate analysis confirms prostate-specific antigen nadir < or = 0.01 ng ml-1 to be a superb independent variable predicting a favourable biochemical disease-free survival (P < 0.0001). Early diagnosis of biochemical relapse is feasible with sensitive prostate-specific antigen assays. These assays more accurately measure the prostate-specific antigen nadir, which is an excellent predictor of biochemical disease-free survival. Thus, sensitive prostate-specific antigen assays offer accurate prognostic information and expedite decision-making regarding the use of salvage prostate-bed radiotherapy or hormone therapy.